Current through September 21, 2024
(a) The Department
shall calculate APR DRG base rates using historical claims data with dates of
payment in at least two of the most recent state fiscal years for which
complete data is available as the base periods for development. The Department
shall:
(i) Assign each certified hospital
providing inpatient hospital services to Wyoming Medicaid recipients to one of
the following three base rate categories for APR DRG services:
(A) In-state Level II Trauma providers, for
which hospital-specific base rates are determined;
(B) In-state free-standing psychiatric
providers; or
(C) All other
providers;
(ii) Establish
base rates so that projected APR DRG payments maintain budget neutrality for
claim payments in the base period for participating acute care
providers;
(iii) Establish a base
rate for free-standing psychiatric provider to include an additional $600,000
annual allocation to maintain funding at levels prior to APR DRG
implementation. The following shall apply to such base rates:
(A) Only one base rate is available to each
provider, per time period;
(B) The
base rate represents a dollar amount used in the APR DRG calculation of
reimbursement for a hospital stay;
(iv) Use transitional base rates for the
first 12 months after the APR DRG implementation. The following shall apply to
such transitional base rates:
(A) During this
transition period, provider-specific APR DRG base rates shall be calculated so
that estimated APR DRG inpatient hospital payments in the base period do not
increase more than five percent or decrease more than four percent as compared
to payments under the pre-DRG model;
(B) Following the 12-month transition period,
providers shall receive the base rate from their assigned base rate
category;
(C) During and after the
APR DRG transition period non-participating providers shall be paid the "all
other provider" base rate as specified in Section 5(c)(i) for APR DRG payment
calculations;
(v) Post
base rates for each provider category on the Department website. New rates
shall be posted with a provider notice sent by the Department when any changes
are made to the APR DRG base rates.
(b) The Department shall assign each claim an
APR DRG code and Severity of Illness (SOI). APR DRG code is assigned a relative
weight that reflects resources that are used to deliver the services associated
with the assigned APR DRG categorization. Relative weights will be determined
as follows:
(i) Calculated using a national
dataset; and
(ii) Adjusted for
anticipated documentation and coding improvement (DCI).
(c) During the rate modeling for the provider
base rates used in the initial year of the APR DRG implementation, the
Department shall apply a DCI factor of five percent to the relative weights to
account for anticipated coding improvements made by providers following the
implementation of APR DRGs.
(d)
Following the first year of APR DRG implementation, the Department shall review
coding improvement and may make future DCI adjustments to account for future
provider coding improvements. Any future adjustments shall be reflected within
the plan language and implemented upon approval by CMS.
(e) The Department shall allow only one
policy or age adjustor to be applied per claim; the applicable adjustment
factor with the highest value shall be applied to the APR DRG relative weight
on the claim. The Department shall apply the following policy adjustors:
(i) A pediatric policy adjustor of 1.3 for
pediatric claims where a recipient is younger than 19 on the date of
admission;
(ii) A policy adjustor
of 1.2 for Mental Health DRGs;
(iii) A policy adjustor of 1.2 for Substance
Abuse DRGs;
(iv) A policy adjustor
of 1.5 for Obstetrics DRGs;
(v) A
policy adjustor of 1.9 for Normal Newborn DRGs;
(f) The Department shall make outlier
payments for high cost claims that exceed a predetermined fixed loss threshold.
(i) The fixed loss threshold is specific to
each of the below provider peer groups. Each provider peer group's fixed loss
threshold is equal to two times the standard deviation of claim cost for all
APR DRG base period claims for the following four peer groups: acute care
hospitals, critical access hospitals, freestanding psychiatric hospitals, and
children's hospitals. The following shall apply to the fixed loss
threshold:
(ii) If a provider's
costs for a claim exceed a threshold the provider shall receive an outlier
payment.
(iii) The outlier payment
shall be calculated as follows:
(A) The
Department shall identify the cost of each claim by multiplying allowable
charges on the claim by a hospital-specific cost-to-charge ratio;
(B) Participating providers are assigned the
most recently available provider-specific cost-to-charge ratios developed
annually by the Department as part of the QRA supplemental payment
program;
(C) Non-participating
hospitals are assigned the statewide average cost-to-charge ratio for the
outlier calculation;
(D) If the
calculated allowable costs less the DRG base payment exceed the provider's cost
outlier fixed loss threshold, an outlier payment shall be added to the DRG base
payment; and
(E) The outlier
payment shall be 75 percent of the calculated allowable costs less the DRG base
payment that exceed the provider's fixed loss outlier threshold.
(g) The Department shall
provide a discharge capital payment to participating providers. The following
shall apply to a discharge capital payment:
(i) The Department shall set capital payments
at $277.87 per discharge, as determined during the 2010 level of care rebasing,
and may not be inflated
(h) The Department shall apply transfer
payment adjustments to claims for services provided to a patient who is
transferred after admission from one acute care hospital to another acute care
hospital. The following shall apply to such transfer payment adjustments:
(i) The Department shall not apply transfer
payment adjustments when a patient is discharged from an acute care hospital to
a skilled nursing or rehabilitation facility, or when a patient is moved to or
from a distinct part hospital unit of the hospital or from one unit to another
within a hospital.
(ii) The type of
transfer-to facility is determined using the patient discharge status billed on
the institutional claim. Acute-to-acute transfer claims are identified using a
distinct list of patient discharge status codes. The Department shall list
these codes in related provider policy manuals.
(iii) For a provider transferring a Medicaid
recipient, the DRG base payment is calculated as the lesser of the calculated
APR DRG base payment or the calculated APR DRG transfer per diem
payment.
(iv) The APR DRG per diem
is calculated as APR DRG base payment divided by APR DRG average length of
stay.
(v) APR DRG transfer per diem
payment is calculated as APR DRG per diem multiplied by (Length of Stay plus
one).
(vi) Claims from providers
transferring a patient and from providers receiving transfers can receive
outlier payments.
(vii) Transfer
payments do not impact the claim payment for the provider receiving a patient
in cases where that provider does not in-turn transfer the patient.
(viii) Transfer status is not considered for
certain neonate transfer DRGs. In these cases, the transferring provider will
receive the full APR DRG payment instead of a transfer adjusted
payment.
(i)
Reimbursement for less than one-day stays shall be based on an APR DRG perdiem
and shall not include outlier reimbursement or capital payments. The Department
shall review all inpatient stays lasting less than one day.
(j) The Department shall use the 3M APR DRG
grouper to review for hospital acquired conditions (HACs) based on present on
admission (POA) indicators required for hospitals' submission on all APR DRG
claims.
(i) Hospitals shall document a valid
POA indicator for each inpatient diagnosis, pursuant to CMS regulations in 42
CFR § 412.
(ii) The Department
shall use POA definitions as outlined by CMS.
(iii) The Department shall not provide
additional reimbursement for the treatment of an acquired condition if the
presence of a HAC would increase payment.
(k) The final APR DRG claim payment is
calculated as follows:
(i) Claim Payment =
APR DRG Base Payment or (APR DRG Per Diem X (actual length of stay + 1)) +
Outlier Payment (if applicable) + Capital Payment (if applicable).
(ii) Final reimbursement amounts shall be
equal to a claim's allowed amount minus any deductions for recipient cost
sharing, patient responsibility, third-party liability or HACs.
